So, you know, this morning we briefly talked about some aspects of concussion with some of the talks we had and how it relates to ADHD and learning disabilities, and then we also talked about how mental health concussion maybe was, you know, a little bit like mental health is now where people were a little worried about disclosing it. And you know concussions made it when an orthopedic conference gives you a whole hour and 15 minutes. So we, you know, we're making headway. So, you know, we've got about an hour, hour and 15 minutes, we'll have three talks and then a panel discussion. And we're really lucky to have our first speaker, Ruben Etchemendia, who I've gotten to know over the years as part of the NHL's concussion subcommittee. He's a director of the NHL's neuropsychological testing program and co-chair of the NHL NHLPA concussion subcommittee. Also the chair of major league soccer, the MLS's concussion committee. Also works with U.S. soccer and is really a leader in the world in this, and a leader of the concussion and sport group. So we're going to have him speak on the SCAT 6. As you know, the last Amsterdam meeting was in, and the publications that came out last year. So Ruben, thanks for joining us here in Chicago and the floor is yours. Thanks, Duren, and thanks to Brad, Duren, and AOSSM for inviting me to this meeting. It's always fun to come to this meeting. And my task today is just to do in 15 minutes what we would normally do in three or four hours. So we're going to try to go through these things relatively quickly. Apologies to the NHL docs who've already seen some of this stuff. So it'll be a reminder for you, at least I hope that's the case. We were told to first come up with the disclosures. As Duren mentioned, I work with the NHL MLS, the U.S. Soccer Federation. I also have a grant with NFL Long, but we're looking at longitudinal care of retired football players. With respect to the Amsterdam conference, I was on the scientific committee, the expert panel, and I had the lead on the SCAT 6 and the CRT 6, some of which we will be talking about in short order. So as you may know, the Amsterdam meeting is based on systematic reviews and a series of systematic reviews that then give rise to what is the consensus statement. So those systematic reviews analyze all of the literature and examine that literature, examine the quality of that literature, and then use that information to come up with the recommendations with respect to the concussion programs and protocols and management. So we're going to focus on the acute screening, which is the recognized component, and I need to give a shout out to Duren, who is also part of this systematic review, and also Kim in the back, was very helpful in terms of dealing with some of the tools issues. This is the title of the systematic review, and just to give you an idea of the breadth of the systematic review, we wanted to review and evaluate the literature across the world related to the identification and evaluation of sports concussion, specifically within the acute phase of injury, and we identified the acute phase of injury as less than seven days, among children, adults, adolescents, and then use this information to provide recommendations for how we're going to make the SCAT 5 into the SCAT 6, what do we want to hold on to, what don't we want to hold on to, while trying to really stay as close to the SCAT 5 as we could, because you don't want to reinvent the wheel every time that we do this. It's not necessary to do that, but we did want to tweak some based on the literature that we looked at. We had six overlapping content domains, cognition, balance and postural stability, ocular, motor, cervical, and vestibular, emergent technologies, that was where Duren was the lead, neurological examination, autonomic dysfunction, and pediatric. So to give you an idea of the breadth and the depth of this systematic review, we identified 12,192 studies that were reviewed for this endeavor. Of that 12,192, we reduced it down to 627, which then dropped down to 423 that were directly related to the evaluation and management of concussion. Unfortunately, this was the largest review in Amsterdam, which meant we were going crazy for a year and a half trying to get this process underway. And it also got me to say that I will never, ever do it again. After having done it for the last two cycles, I will not do this again. It's kind of crazy. It's time to go into retirement. So the conference had important outputs. One is the methodology paper, the 10 systematic reviews that I talked about, and of course the systematic review. They're going to be focused on the SCAT-6 today, which is an adolescent and adult tool. The others, so that you know about, but I won't necessarily cover unless you have questions about it, are the Child SCAT-6, the SCOTE-6, which is a new instrument for more post-acute evaluation in office, and then the Child SCOTE-6, and then the CRT-6 is something to be used by non-healthcare physicians, those individuals who are typically in recreational leagues, youth leagues, who are watching the game and learning how to recognize and remove. And that's the whole focus of the CRT-6. So what is the SCAT-6? Basically it's a multimodal assessment tool. It's designed to create a standardized evaluation. That's important to underscore. It is there to create a standardized evaluation. It is not a diagnostic tool. It is not a tool that you look at the numbers and then that tells you whether there was a concussion or not a concussion. It allows you to examine all the domains. And as we all know, for better or worse, the diagnosis of concussion remains a clinical one. It is a clinical judgment based on all of the information that is available to you. We don't have a biomarker in this area. We keep trying, but there is no biomarker that's showing up, at least a biomarker that is consistent throughout the spectrum of this injury. The SCAT is most effective within 72 hours of injury, which means it's an acute evaluation tool. It is not a return to play tool. Let me emphasize that. It is not a return to play tool. It's an acute evaluation tool. It's important to recognize that an athlete can have a concussion and still have a normal SCAT-6, just like you can have an abnormal SCAT-6 and no concussion. The trick is trying to figure out what the tool is telling you and what it's pointing you to. Doren mentioned ADHD. Are we picking up this signal because it's ADHD and not because it's a concussion? Are we picking it up because for some reason this player's blood sugar is low? That's going to set off the SCAT-6. Is it an issue that the player is dehydrated? That's going to set off cognition. These are all of the things that we need to take a look at when we're trying to figure out what this tool is telling us. When we look at the SCAT-6 relative to the SCAT-5, what's new? There's a new coordination and ocular motor screen. We have an enhanced red flag section. If you remember from the SCAT-5, there used to be a thing that said, okay, read this paragraph out loud and the player read it out loud. That was the dumbest thing in the world. I don't know why we put it in there. I don't know why, but it didn't do a thing. It was not very good from a clinical standpoint, so we removed it. We also removed the immediate memory task for five words. Five words is not discriminatory. It does not discriminate for even adolescents and children. Certainly, a five-word list does not discriminate at the college level or the elite level or the pro level, for that matter. Now we only use the 10-word list. We added a timed component to the months in reverse. The reason we did that is we found that the concentration subtest of the SCAT-6 had a very significant ceiling effect, which meant it was too easy. If it's too easy, you're not going to be able to pick up that signal. We wanted to make it more complicated without having to really pull in a lot of advanced neuropsych tools that would make this tool too long and too cumbersome. We added the timed component, and we're starting to see that the addition of that timed component is giving us much more of a normal distribution, which is going to help us moving forward. The biggest changes in the SCAT-6 have to do with the revised coordination and balance examination, and we'll go through that in detail because it now does include an optional dual-task tandem gate. And then we had a revised detailed instruction section. Before we get into some of the nitty-gritty here, the other thing that's important to keep in mind is that you really should take a look at the systematic review for the SCAT-6 and the detailed instructions for the SCAT-6. They're separate, and they give you a lot of information in terms of how to use this tool. In the biographic information, you can see that we started to change some things in order to get some more data with respect to the time of injury, first language and preferred language. We know with our data within the NHL that language plays a huge difference in terms of how players perform. So their culture, their language, and their educational backgrounds are significantly related to how they score. So if you don't take into account those variables, you may be misreading the situation. All of the neuropsychologists in the NHL have NHL-specific normative data that has been broken down by age, education, and language. So we have different norms for all of those groups. We wanted to know what the primary symptoms were, how long was their recovery, and when was their most recent concussion. There was a new red flags section, and these are things that should at least open your eyes to something that may be going on that's related to concussion. Some of these did exist before. We added the GCS for less than 15 in this one, and we also talked about deteriorating conscious state and added the vomiting, which wasn't there before. We also had a very detailed flowchart this time for how to go through and do the neuroscreen. And it's very detailed in terms of whether you're having observable signs, what's your Glasgow Coma Scale, whether there's any cervical tenderness, and their coordination and ocular motor screening, as well as the memory and Maddox questions. The important thing to look at here, although it's a detailed diagram, is that all of that has to happen before you even start the SCAT-6. Okay, so you need to get all of this taken care of, make sure that the player is okay to go on to the SCAT-6, and that anything else that's more severe has been ruled out. Lots of questions in terms of observable signs, whether they're witnessed, whether they were observed on video, cervical spine assessment, and the coordination and ocular motor screen. I'm not going to go through all of these. You can look at these on your own unless there are questions later. So months in reverse, as I said, we started to add the timed component. So we have to remember to start the stopwatch when you ask them to do the months in reverse. What that also helps to do is it helps us to identify those players who have been practicing the months in reverse in order to try to cheat their way through, and adding the timed component also helps us to do it. Because if they're doing it in nine seconds or three seconds, then you know that they've been practicing this tool. So now we're going to get into the balance and postural stability issue. So what we had in the past was the MBESS and the Romberg and the tandem gait. What we found is that we needed to change that into a progression of complexity that dealt with static balance as well as dynamic balance, and then added a more cognitive component for the dual task, which makes it more difficult. So the way that this is designed to work now is that you start with the MBESS, or the BESS if you choose to use the foam, which is actually more sensitive. And if you can use the foam, go ahead and do that. But since we're in hockey, we're not going to use the foam. So you start with the MBESS and the BESS. If that is okay, then you go on to the tandem gait. And then if you want to get more detailed, go into the dual task. The dual task is optional. So we know that the MBESS has three stances, maximum of 10 errors per stance. Do not, emphasis, do not do this on skates. It has no validity on skates whatsoever. We've looked at this every which way you can. It has no validity. It should not be used on skates. If the MBESS is okay, then we're going to move on to the timed tandem gait. Here you can use skates. We have found that the skates work well with the tandem gait, and we have separate norms for the tandem gait with and without skates. If they do okay with the tandem gait, the question then remains, particularly if you have concern about any kind of vestibular issues, is this guy's balance really okay? So here's where people hate neuropsychologists. Because we took what was a simple task that says, okay, just walk this straight line one way and then bring it back the other way. And now what we're telling them is this time I want you to do it while doing serial sevens backwards. Okay, so you're walking up and down the line, and you're subtracting seven from the number before it, starting with 100. That really gets the system going. It has a multimodal component, and it's been shown that once you do that with this task, you can really get at any difficulties with the vestibular system and the postural control system. So first you practice it, and what you practice at first is just the numbers. Can they do it? Can they subtract seven from the number before it? If they can't subtract seven, then you try three. But typically you start with seven, and there's a cheat sheet there for you guys so you don't have to be doing it in your head. So you do the practice, and then you do three trials, and you have them counting down. Now you can pick whatever integer you want to to start with. You got to remember, though, if you pick an integer that's not on here, that means you got to count in your head, either that or have it written down. So I suggest you write it down first and not test yourself while you're trying to test a player at the same time. Very effective. What I recommend to folks is if you want to dig into balance more deeply and use this task, do it in your office the next day. Don't do it on the same day, because you really don't need it on that same day unless that's the only issue that you're concerned about, and then you can do it after the game if there's still a significant concern. I would not try this during the acute evaluation in the locker room or in the clinical room. With that, I'm going to stop. We should be there on time. Thanks. Thanks, Ruben. We will, during the panel discussion, have some time for questions from the floor. The next presenter is very decorated. Kim Harmon is the deputy chief medical officer of the National Hockey League. She's a professor in family medicine, orthopedics, and sport medicine, and the section head of sport medicine at the University of Washington, head football physician at the University of Washington. Her and I both know a bit about losing in championship games or series from this year. Currently, she's also a member of the NFL Head, Neck, and Spine Committee. What Kim's going to focus on is concussion prevention and some of the evidence regarding exercise and concussion. Thanks, Kim, for coming. Thanks so much. It's great to be here. Thank you, Doran and Brad, for inviting me in AOSSM. Here's my disclosures. A lot of them Doran already mentioned. I'm also on the NCAA Concussion Advisory Committee and have some grants, none of which really should relate to anything I'm talking about today. I'm going to talk a lot in terms referring back to these systematic reviews that Ruben talked about from the Amsterdam Consensus Statement. As he mentioned, they did 10 systematic reviews, and one was on prevention, one was on exercise after concussion. And so we're going to go over some of the literature from that, but then also some that's come out since then. So first, we're going to start with prevention. And when we're talking about prevention, in this systematic review that was done, there were 220 studies that were eligible. 192 of them were included that had acceptable or high-quality evidence. But I'm really going to focus on the studies that were specific to hockey. So specifically, we're going to talk today about the use of face shields or face guards to prevent concussion, mouth guards to prevent concussion. We'll talk about jugular venous compression devices and actually expand on what was in the systematic review for that. We'll talk about body checking rules, different rule changes, and then some training strategies. So when it comes to face shields or face guards and preventing concussion, there were five studies that looked at and examined the effect of having either a full, a half, or no face shield on concussion. And three of them found that there was no difference, depending on what type of face shield you had on. And those studies were in college players, in elite amateur players. And there was one that looked at NHL players. One study reported that there was less time loss in those that had sports concussion when they had a full shield on versus when they had a half visor on. And the study that looked at professional hockey players showed no decreased concussion rate in those with the different shields. So despite the fact that it doesn't really appear that the type of shield or face guard that you wear has any influence on the rate of concussion, we do really think that there is some opportunity to decrease concussion by working with the helmet. And so Bill mentioned this in his talk today. This is the helmet impact testing poster that we put out. And certainly in the NFL, this is where they've seen a lot of improvement in their helmet technology over the last 10 years. And I think that there's some room in hockey to really make some headway here. So there's no evidence that visors or half visors prevent concussions. But there's lots of other ways, as we heard in our maxillofacial talk, that they do prevent injuries. Will the mouth guards prevent concussion in hockey? I guess that's the next question. I would say, first of all, you actually have to wear the mouth guards if they're going to prevent them. The systematic review came out with a, this was a new statement this time for this review. And it said, mouth guards are associated with a 20% lower rate of sport-related concussion in ice hockey. So that's a big statement. But I want to dig a little bit more into that. So this basically comes from two studies that were in hockey. If you look at that graph right there, and I guess I've got a pointer, this is a forest plot right here. The middle line right here is just when there's no effect. If there's an effect in the wrong direction, it goes over here. If there's a preventative effect, it goes this direction. The size of this blue square means that that was a big number of studies. You can also see these were both high-quality studies. This study was in youth athletes right here. This study in here was in NCAA athletes. You can see that there is a much smaller number. And then the whiskers on either side are the confidence intervals. And so this is sort of the overall effect. And the thing is is that most of the results of this statement, which is true statistically, was driven by the youth hockey studies. And so certainly, I think that you can say that mouth guards are associated with a decreased concussion rate in youth hockey. Extending that to sort of other levels, I think, is that we don't have enough information yet. And certainly, when we look at other sports, the other good studies have been done in rugby, and there hasn't been shown to be a decrease in concussion with the use of mouth guards in rugby. And so I think we're still going to hear more to come on here. As in the face shields, there's a lot of other good reasons that you should wear mouth guards. But concussion prevention in older athletes is not going to be one of your primary ones. How many people have people asking them about these jugular venous collar compression collars or using them? Anybody have players using them? And what are you guys thinking about them? Well, let me sort of tell you sort of what I've seen with them. So the proposed mechanism is that the brain is floating around the skull in a bunch of cerebrospinous fluid. You put some pressure on the jugular veins, and that increases the pressure in the brain, and it reduces brain slosh and can be protective. The Q collar was FDA approved in October of 2021. And in the FDA approval statement, they actually said that today's action provides an additional piece of protective equipment athletes can wear when playing sports to help protect their brains from the effects of repetitive head impacts. And so it was a pretty strong FDA statement. There's been a lot of press about this, both positive and negative in the lay press. And certainly, a lot of just hype surrounding it. The FDA later came out in October of 2022 with a summary of their previous statement. And they basically reiterated the reason that people might want to wear Q collars, and then came out to mention these additional limitations to the studies that they'd made the approval on. And that includes that the Q collar hasn't been demonstrated to prevent long-term cognitive function and deficits, and that really the ultimate clinical outcome hasn't been evaluated. That the use of imaging studies as a future indicator of brain injury hasn't been validated, and that the data didn't demonstrate that they can prevent concussion or serious brain injury. So seemed to walk back a little bit on their initial sort of enthusiasm for this device. I'm working with a student. We're in the midst of doing a systematic review on this. And there's now seven studies that are out that look at imaging changes in athletes to wearing the Q collar. It's interesting to note that most of these are funded by Q30, which is the company that owns the Q collar. And that doesn't necessarily mean that they're bad studies, but it's just something to sort of keep in mind. And these changes right here, these are all different MRI changes. So diffuse and tensor image, mean diffusivity, radial diffusivity, axial diffusivity. And this is non-colored people compared to colored people. And you can see that in some of the studies, some of these indices go up, and in some they go down. And so my sort of basic conclusion is that there's definitely some statistically significant changes that you can find between colored and uncolored people on imaging studies. But they're different in different studies, and the significance at this time is really unclear. So I guess in summary, I would say that these colors haven't been shown to decrease concussion, that the effects on repetitive head impact are unclear. But on the other hand, they haven't been shown to create any harm. And maybe other than a false sense of security or other things that you might think of. So that's sort of, I think, the latest up to date on that. What about body checking? Well, there's eight studies that show a decrease by 58% of sports-related concussion in children and adolescents that don't allow body checking in those leagues. And again, this is that forest plot again. You can see that there's a bunch of studies. There's a bunch of high-quality studies, acceptable studies. They're all pretty consistent in what they show. We don't have any studies in leagues in older people, because that's really sort of an essential part of the game as we get older. But in young youth leagues, it seems to decrease the concussion rate. Rule 48, Bill also mentioned this. This was introduced in the 2010-11 season, which made targeting opponents from the blind side illegal. It was amended the next season to make all hits to the head illegal. And this is a study that was mentioned in the systematic review. Looking at the data from the year before Rule 48 went into effect to the two years after, there was actually an increase in concussion rate. And so people are sort of unsure what to think about this, because it seems like hitting people in the head would increase concussion rate. And I would just say that this study was done on publicly available data, and that there's been a number of different instances when people have used NFL, NBA, NHL data that's publicly available. And it's just not super accurate. And again, we think that there is, certainly when we look at mechanism of action for concussion, that's one of our primary mandatory signs is getting hit in the head. And so while this study didn't show anything, I think there's still reasonable pragmatic indications not to allow people to hit people in the head. Training strategies, there's no studies in hockey at all. In football, in American football, vision training was shown to have an 85% reduction in one study. And in several other studies, in both rugby, American football, volleyball, and soccer, core strengthening as well as balance work and other exercises have been shown to significantly reduce concussions. And so this is an area where it's interesting. There's some good information in other sports. The training strategies that people use are different in different sports. But it might be interesting to look in hockey if there's something that we can do in the neuromuscular training area that might lead to a reduction in concussions. We're going to switch gears a little bit and look at exercise after concussion. And I think before we look at what we're currently seeing, we should remember a little bit about where we've been and where we're going. And this is really, I think, one of the biggest changes in the latest consensus statement is really a focus on getting people moving and exercising earlier. And so as early as 2012, when the fourth consensus statement came out, the recommendation was that the cornerstone of concussion management was physical and cognitive rest until all the acute symptoms resolved. And then you begin a graded return to play. In the Berlin consensus statement, they walked back on that a little bit and said, really, that there's currently insufficient evidence for prescribing complete rest, but didn't really recommend active exercise. And in the most recent consensus statement, they've come out more strongly saying that the best available evidence shows that recommending strict rest doesn't work and that people should become active with activities of daily living, really in the first 24 to 48 hours after concussion, and begin an exercise program that doesn't significantly exacerbate symptoms soon thereafter. And so there's a significant amount of evidence for this. And so this is looking at the grade quality of the evidence. You can see there's, if you look at just prescribing physical activity, so this is more talking to people about doing physical activity, but not giving them 20 minutes on the treadmill at 120 beats per minute sort of thing. There's lots of study, and there's moderate evidence that it's beneficial to do that. For prescribed exercise, there's high level of evidence that there's a beneficial effect. And then for rest, there's moderate evidence that that is not beneficial. And this is the forest plot for prescribed exercise. And again, you can see sort of that most of the studies line up here in terms of showing it beneficial. And when you put that in a meta-analysis, if you prescribe exercise, it seems that symptom resolution occurs about 4 and 1 days earlier than without active prescribed exercise. There's also evidence that supports that this is effective when people have persistent symptoms and can help with that. So most people when they're doing this, are people using the Buffalo concussion treadmill test in here? So that's what we've been using for some years now. And so what that is, for those who don't know, you put somebody on a treadmill that's going 3.2 to 3.6 miles per hour. You record the heart rate, the rating of perceived exertion using the Borg scale here, and then also get their pre-test symptoms. And then every minute, you check how they're doing and increase the ramp grade by 1% until they either have an increase in more than 3 in their symptoms, or they get to physical exhaustion. If they get to 3 more than their baseline symptoms, then if they get to that rate when their heart rates say 160, you prescribe them an exercise program that is somewhat less than that and go from there. So exercise after concussion, where do we land on that? That light activity of daily living is tolerated for the first 24 to 48 hours. I would tell you that I might be a little bit more aggressive than that with my players, and that you may begin increased physical activity that doesn't significantly exacerbate symptoms. Or you can do a more formal assessment, like a Buffalo concussion treadmill or bike test, and give them a prescription. So that's my thoughts about prevention and exercise. And if you have any questions, feel free to reach out to me. Thanks. So I'm going to do the last talk before the panel discussion. And my talk is really about treatment of concussion and assessing with a purpose. I think as started in sport medicine, concussions, of course, rest until they're better. And we always used to tell people, everybody's concussion is different. And I think that's very true, as all of us here have treated concussions. But people also say, Doc, what do I do? Or how do I approach this? What can I do? And it kind of plays off Kim's talk a little bit. So I'd just like to thank all the teams and clinics I work at. And this is that International Collegiate Sports Group that Bill Daly spoke of. We meet quite regularly by Zoom and once a year. And I have a role as the CMO of the CFL on this group. And Mark Olbry, who's also here, is part of the IIHF. And I know that Ruben has been to these meetings on behalf of the NHL. And my conflicts are the same since last time I did this. Ed took all the funding from me. We're going to talk about just a brief definition of sport-related concussion. And really, we're going to focus on concussion subtypes that are really an important roadmap to help guide treatment. And really, I found this approach to be really helpful for the athletes. And then we're going to talk a little bit about the vestibular ocular motor screen, which Ruben touched on the vestibular ocular system a little bit, as that's been a little bit of an addition to the SCAT-6. But the SCOT-6 is where we discuss using the VOMS a little more. So if you're around my age, which I'm the same age as this hockey player here, Eric Lindros, we always wondered why a player who was so much bigger than everyone else at that time was starting to get these dramatic signs on TV of not being hit very much and falling. And I think this is when I probably started to get interested in concussion as I was doing my studies. And then some of the first definitions of concussion came out in the Congress of Neurological Surgeons, where they said this was a clinical syndrome characterized by immediate and transient post-traumatic impairment of neural function due to brain stem involvement. So initially, they thought it was maybe the brain stem involved. I think we know it's more global than that. My favorite definition is, as I say to my athletes, is you have to have a trauma. Or my MBAs or people who maybe have secondary gain. But you have to have a trauma and some sort of alteration in consciousness or your mental state. And you don't have to have a loss of consciousness. We did a study about 15 years ago where we did a questionnaire to junior hockey players, professional football players, and college football players. And then we did an education piece and then looked at it at the questionnaire again. And the players thought that you had to lose consciousness in order to have a concussion. And they also thought an MRI or imaging was needed. And this was about 15 years ago. So it helped us tailor our education at the university level. Amsterdam, this is their definition of sport-related concussion, which is very complete. And then the 11Rs, which I think was a really good way to organize the paper. And we've seen that evolve. And Ruben discussed that. So just to remind everyone that symptoms are what you feel as a person. And the symptoms highlighted in red have been found to be more specific in the hockey-related literature. I won't restate them all, but really that headache, pressure in the head, not feeling right, feeling in a fog, feeling slowed down. And then the signs are what you see. And this is really what we are observing as medical professionals, what our spotters are observing in organized sport. And these are important, the lying motionless, slow to get up after a direct or indirect hit to the head, that disorientation or confusion that usually our athletic therapists or trainers are able to tell us as they're the first ones to see, the athletes, that blank or vacant look, and then the motor in coordination, where you get hit, and I have a video of this, and then the athlete gets up and maybe stumbles down. I think it was really obvious maybe in the NFL case with a quarterback from Miami, and then any facial injury after head trauma, you really have to think about a head injury and any of the posturing. This is an example of posturing in an NHL player. This is someone with that little bit of condensation, another NHL player indicative of a loss of consciousness and maybe an alteration of their breathing patterns, and this is a video. Can we play this video, please? This was in Vegas. The player's in the bottom of the screen. You see him falling backwards. There'll be some other angles, and if you just watch right about now, he just kind of has a little bit of a stumble, but we see it better in this view as he tries to get up, and he stumbles, so this is an example of motor in coordination, and then finally, this view, you can really see where he hits his head on kind of that occipital temporal area on the boards. Thank you. So you've diagnosed a concussion, now what? So obviously, we've talked about, and Kim just touched on this dark room and rest message that I think anyone who works in sports hasn't been doing it, but anyone who works in clinics, we still get people to this day who, in Canada, who knows, I might see them a year later. Well, it's really not that bad, but two or three weeks later, they come in, and they said, I haven't been doing anything because I went to an emergency department, and they said I should not do anything at all. I shouldn't go to school until I have this referral. So this is still something I commonly see in my office. Does anyone else have that problem in clinical practice who see concussions? Yeah, so Kim and Ruben. So still, this is something that I think the concussion support group has done a good job of debunking, and Dr. Letty, but it's still commonly heard. And I always say, every other injury we have, we get people to move. If you have a knee injury, there's many different treatments, whether we're doing BFR, post-op. Now, a lot of things to keep muscles going and other body parts going, so we obviously have more specific rehab now with concussion. So that's where I get this, you treat with purpose and treat with what the athlete is, is really their specific concussion symptoms. So the concept of subtypes, when this original questionnaire that came out from Karen Johnston's work in the McGill ACE questionnaire, it was organized in a way that really looked at, if you look at the physical symptoms, headache and neck pain, that's in the top part of this questionnaire that we see on the SCAT now. And then the balance, vestibular, ocular, so some of that dizziness, that blurred vision and balance problems, that's organized as well. The cognitive symptoms, feeling in a fog, feeling slowed down, not feeling right, the difficulty concentrating and remembering are again organized together. And then our mood symptoms of irritability, emotional problems, anger, depression and anxiousness. So it was always nicely organized. And then in 2019 in neurosurgery, they really talked about this in a little more detail in subtypes and they talked about five and they also said sleep disturbance and neck-related strain are also things that can be unique. But in the end, it's all a Venn diagram because we all know that our concussion athletes early on might have a little bit of everything, but typically after two or three days, you can really see one or two subtypes that are predominant and then that's how you can focus your treatment. So I was lucky to be a part of the Active Rehabilitation Project and this was done through UNC, Jonah Register-Mahalik and Kevin Guskiewicz's group. We had two sites with the Canadian Football League and also the University of Alberta, but there are 28 sites that spanned a lot of sports that were contact sports and we had 3,500 athletes. So basically what this project did is based on your subtype, you had buckets of treatment and athletes would start to do these buckets of treatment after two or three days and that was the experimental arm. The other arm was what we usually did in sports at this time. The study was, we did it about three or four years ago where you'd have an athlete and you'd do the aerobic exercise from John Letty's work. So this is just an example of the experimental arm, what we call the multidimensional rehabilitation arm. So this is an example of a progression of someone who had the vestibular ocular subtype. So phase one would be very early on, it says massage, heat pack and then wide stance for balance. And then as people continued to go on, we would do Y balance or we do some static balance on unstable surfaces like the foam, like we do in the best. And then as time went on, we'd get a little more advanced with tandem walking and then we did again Y balance with an unstable surface like foam and then get a BOSU ball involved. And then phase four was more dynamic where you'd have sports specific, so maybe lunges with a ball toss and then maybe convergence type exercises with a BOSU ball. And then finally, phase five would be as athletes get closer to return and their symptoms are negligible where you do some sports specific ball tosses here. This is obviously more with a basketball player. But what we do is we'd have an athlete do these buckets. So if they had a cognitive subtype and a vestibular ocular, they would have a whole series of cognitive exercises to do and we didn't do any more than a couple of buckets at a time. So we were lucky because in the CFL, we divided the league into East and West and the West side, we got to do the multidimensional rehabilitation where the East side was a control. So we got to see a lot of this in kind of play. And this is just what I basically was explaining about the experimental arm and the control arm. And we had 125 concussions in the enhanced graded exertion, which was the way we usually would treat concussions than the multidimensional active rehab was 105. And it was a two year perspective study period that we did. So what did we see? The first thing is by getting people to do these buckets early, there were no harm. There were a few athletes who would have an increase in symptoms in the multidimensional rehab arm, but they were dissipated by the next day. The full data will be published soon. We've done some publications on the safety, but really we found that it did enhance recovery of concussion compared to the aerobic exercise group. And then the thing that we did find, when can you establish the subtype? We really found that we really needed about 72 hours to really know what subtypes they were in. So after 24 hours, we usually just got people to do some light aerobic exercise. And the athletes were very compliant. There was something to do that was specific to them as athletes. And so stay tuned for kind of the final numbers on this. So again, just wrapping up a little bit on subtypes. If you have a cognitive subtype, get your neuropsychologists and maybe your OTs involved. Mood, anxiety, behavior, get your team psychologist involved early. Your vestibular physio for vision and balance. I usually like starting with the vestibular physiotherapist before I go on to optometry or vision therapy because I still think that it's a little too frequent for people early on. And then physical symptoms, obviously headache, migraines, neck pain. Sleep can be managed by physicians. And then physiotherapists, obviously for neck pain that we use in our athletic therapists on our team. So I really think this has been very helpful for me clinically, both in a sport medicine setting and then in a clinical setting, seeing concussions, really giving people a roadmap and then using your whole multidisciplinary team as well. So last few slides, I just want to talk about ocular motor stressing. You know, these are the people with this subtype who come into your office wearing sunglasses. They can't read, they can't follow the computer. Maybe the athletes who can't watch film and really have a lot of headaches with screen difficulties. And, you know, I think the NHL and many other leagues have started to add the vestibular ocular motor screen as part of their assessment. You know, you can find this UPMC first publishes about a decade ago or more. And it takes about five minutes to do when you do it a lot. So, I mean, we really early on got at the university and both in the CFL and NHL got a lot of baselines to get people really used to doing this who weren't used to doing it before. But in an acute setting, it really will bring out the vestibular ocular symptoms. People won't like doing even smooth pursuits where you're just following. And then the saccadic movements where you're going back and forth very quickly. Near point convergence can give you that objective measurement. And then, of course, adding the head shake with the vestibular ocular reflex and then the body movement with visual motion sensitivity. This is kind of a scale that you'll find when you look at this is really it's very subjective. So, you ask people after you do each component of the VOMS, their subjective symptoms of headaches, dizziness, nausea, and fogginess. And that'll really give you a sense. And then you'll repeat this again as people continue to recover. So, just back to our objectives, really I just wanted to maybe get across that importance of subtypes in helping guide treatment and also assessing and making sure you're hitting on all these areas because it really gives a great roadmap for people. And I think they're just, especially in a sport medicine setting, a lot of the times our athletes with concussions, everyone asks them every day, how you doing, how you doing? And they look normal. They don't have a cast on. They're not wearing a sling. But this just gives them, okay, these are my subtypes to work on and my buckets to work on. These are three references that I really rely on, the concussion and sport group. ACRM has a diagnostic criteria for mild traumatic brain injury. So, maybe some of you who don't work in the sport setting or also work in the non-sport setting in MVAs. And then the living concussion guidelines are out of Ontario. And they've been a very active evidence-based group and a very organized website. So, thanks. Thanks for your attention. We're gonna now bring the panel to go over any of the questions you have. So, Ruben, Kim and Tom, if you can come up to the front and we'll start the last part of this. You wanna cast your question? Orthopedic students love classifying things. We have a classification for everything in the world. A classification's only as good if there is some outcomes data. So, in your gestalt, and I know you're still early on in this process, so I'm not, it's not validated, obviously. How would you rank subtypes in terms of return to play? Which subtypes are bad? I think we all have our gestalt in your data. Do you have anything in which ones are less bad? How would you grade the subtypes? I'll maybe start, and I think this is a good question for Ruben and Kim as well. But we do know that from an evidence perspective that probably the cervical spine treatment with physical therapy, the University of Calgary group has shown that that's helpful. I think when you look at things, the cognitive or affective disorder, the depression in conjunction with ADHD and learning disabilities take longer to recover. And then the vestibular ocular subtype, which I think we're still trying to understand the best way to treat. So, I'd say kind of those two are probably the ones in my clinical experience and based on evidence. Ruben, do you wanna add to that on the ones, the subtypes that take a bit longer? Yeah, I think that one of the issues with the subtypes is that you have to remember that there's a large band around the subtype. There's an average in the middle, but a large band around that. And when you have the Venn diagrams, when you have more than one of those subtypes spinning around each other, that's definitely gonna prolong the recovery. And without question, we know from lots and lots of data that the mental health factors that come into play in both created by the injury and also created by the inability to play on all the other factors that are associated from a psychological standpoint that are associated with this injury, that makes it worse. If you have a preexisting mental health condition, depression or anxiety, that's gonna make it worse. If you have prolonged symptoms, when people ask me all the time, what do you do with prolonged symptoms? Find out where the anxiety is. Because that's really what's gonna end up driving a lot of those symptoms. And I would just add to that, that there is no standardized way to define subtypes. And so there's a way the UPMC group does. And in that, in many of the subtypes, there's the same symptoms. So dizziness, fogginess are in several different subtypes. And so you end up most people that get concussed, particularly early on, have three, four subtypes. And so how is that helpful to you if you've got all the subtypes? We know for lots of evidence supports the fact that the biggest indicator of return to play is the symptom burden, the overall number of symptoms and the symptom burden. And how is that really just sort of an analogy of these different subtypes? So I, like Dorenda, have not really found the subtypes super helpful until sort of later on in the course. And so if something starts to declare itself later, but a lot of the concussions that I see, they just get better pretty quickly. And we start vestibular therapy on everybody soon because it's easy. And we start exercise on everybody and then sort of see where we go from there. I have a question from our virtual attendees. Any tips or tricks for getting useful testing data for players who are fastest or familiar with these types of protocols to just kind of game it a little bit? Yeah, from the testing standpoint, switch it up. There are three different versions of the SCAT. So definitely switching that up. And if you've got a player who's gone through it 10 times or 12 times, and even switching it up doesn't help, then get creative and start throwing a couple of curve balls at them. And then they don't know what to do with it because they've practiced it and then they can't get out of that bubble to try to answer it. One of the things that I do is I'll mix up the word lists for them. And that really throws them because they've recognized that all these words go to, you know, apple, carpet, saddle, bubble, that they go together. But if you mix it up on them, then they're like, I don't know what to do. So, and that's where being the clinician really comes into play, right? In the last analysis, you have to be a clinician and take a look at what's happening with that player. Because as Durant said, that they're different. You know, everybody's different. Armesh. I found your talk to be interesting. Can you talk a little bit about your progression that you talked about the M-BEST, then moving on, and then finally the combined version? Why even do the M-BEST and the other one if you can just, why not do the combined version as part of your SCAT 6? Well, because it takes longer for one, and a lot of people are not comfortable with that. The good thing about the M-BEST is that if you find an abnormality, you're done. Okay, you don't continue with it. But if they're able to do the M-BEST, and then you move to the tandem game, and then you move to the dual task, you're increasing in complexity. You can increase in complexity from the beginning. But it takes longer. People will find it less comfortable to do that in the acute setting, and would want to do it afterwards, after the game or in the office. It's a great test, but until you're familiar with it, it's harder to do. Tom, are you doing the M-BEST or the tandem gate or both? We typically do the M-BEST. We do that baseline, and then we find that a little bit easier to do in-game. We do have, obviously, players are taking their skates off, but that's what our physicians have been comfortable with, and we do as well. And in goalies, do you have them take off their pads? We do. That's another good point. When you're doing the tandem gate with goalies, if they have their pads on, you're creating an issue for them, unless they had their pads on at baseline. Because you want to make consistent what happens at baseline, and then in the acute injury evaluation. Tom, do you think there's... Yeah, I think so for sure. And I think it even extends to the point of their teammates. Teammates will see their buddy, or maybe they're sitting on a bench and something is missed, or in the room, or maybe they're out with them after a game. I've seen that, quite frankly, when they'll come to us and say, hey, check on Ruben here. He's acting a little different. And I think that's one thing that's missed quite often. And I know a lot of people in research side or the lawyer side may not want to hear it. But from our standpoint as athletic trainers and therapists, we have the benefit of spending nearly every day with these players. And if there is some slight change in their behavior, we're going to pick up on that. So if a player comes off the ice, and even if it's a discretionary evaluation, and we're talking to them on the bench, we can pick that up pretty quickly if they're off. And there's really no way to quantitate that, to document it. But it's just something that's an important fact of what we use as an assessment tool. It's just our knowledge of the player and what their teammates are reporting. I always thought the most diagnostic tool that I have is when I'm sitting there doing the scat, the athletic trainer standing behind the player going. Just following up, Tom, on what you said, the discretionary assessment. So in the NHL, as Bill Daly talked about, the mandatory, if you see the signs that I had up there, obviously that's a mandatory evaluation, or sometimes an automatic diagnosis of concussion with loss of consciousness, motor incoordination. But what would be your approach when you have someone with these soft signs? You get a call, or you notice something. What are some of the things that you would ask in a two minute evaluation to give you an idea whether they need to have a formal evaluation? The first question is just how are you feeling? And a lot of times they'll either honest or not. But then you're going to ask just a quick question, what happened? What did you feel during the play? Did you get hit in the head, or was it your shoulder? Where do you have pain anywhere else? So just the simple questions that you're asking, you may start getting into the, if you're questioning where we are and what's the score, it's probably at that point you need to pull them off. Fair. It seems like a concussion. Yeah I think I I think I I read 142 full-text articles as part of the review about about this imaging I mean I think that the difficult the difficulty is is you know depending on the type of imaging whether it's DTI I mean you know whether someone's mood is off whether they're excited and then do we have a baseline of where they're at and there are some studies there that said oh the brain is different three months later but people have absolute feel absolutely normal and they have returned to contact sport with with no issues and I think you know Ruben alluded to you know we just don't have some people will say you know who are very in that space so we have it but it's not practical and I think if you look at the time it takes to do a DTI MRI I mean we have one experimental one in Edmonton but I mean I think you know we're not we're not quite there we can't see the x-ray yet Kim or Ruben anything to add to that yeah I mean you know they you see persistence of changes in EEG long after symptoms go away you see elevation of biomarkers blood biomarkers long after things go away but you can also say the same thing about a muscle when you tear a muscle it histologically will never look the same as it did before and we send people back to play on their hamstring strain way before it looks normal like histologically or even on imaging and things like that so there's some correlations there and I guess the question is really you know does it matter I think it's not only doesn't matter but what does it mean right because is what we're seeing in some of the imaging a normal reaction to an abnormal event is it a byproduct of the healing process that's creating a difference between the controls and those who are injured and we simply don't know the answer to that and if you want to have fun sometime take a look at the DTI studies and take a look at the standard deviations around any of those images they're huge the individual variability is crazy and without having good normative data it's very hard to interpret those data I have a question about baseline testing you know from from my perspective and you know even in youth sports whether I'm covering you know a u16 triple-a team who you know are hitting and contact I found I found very useful and I know the you know the consensus guidelines have have changed and the language went away from baseline and went back so maybe if you can chat about you know not in the NHL population or maybe even that junior hockey or college hockey population we know the brain is still developing a little bit about baselines baselines are tricky right because they're very useful when you know how to interpret them they're not very useful and could actually be misleading when you don't know how to interpret them because a number of different factors one when you're baselining somebody you're baselining them in a very different condition and a very different mindset than they are when they think they're going to get pulled from play right so there's a lot going on there if you don't understand test retest reliability if you don't understand the variability across these scores then it becomes difficult however having said that what I talk to people about with baselines is baselines can be very very useful if you have the resources to do the baselines and you have the resources to get someone to help you interpret that test retest component of that in most situations at the youth level that does not exist most schools can't handle all that but then they're told you have to do this it's it's mandated that you do it because everybody else is doing so and I've been involved in those situations so what you have is a lot of data but they don't know how to use it with respect to the post-injury data so it becomes useless to have the baseline if you can do a baseline and you can get somebody who knows how to interpret it to do it by all means do them particularly if the individual is from a culture that's different than the majority culture that becomes a huge issue in there but if what you're doing is you're doing a baseline because you're checking off the box that says this is our concussion program then it's not very useful it can actually be very misleading so this is a question from one of our virtual attendees follow on so does the NHL use Sway or impact testing at all yes we don't use Sway but you have to remember that the NHL don't tell Bill I said this that the NHL is resource-rich right they have so in the NHL every club has at least one neuropsychologist we do baseline testing with impact as well as a number of other different tools and we do a more complete post-injury evaluation that takes a look at neurocognitive computerized neurocognitive testing as well as traditional testing as well as psychological factors embedded in that so I think that what the NHL does what the NFL does what MLS does are great but they have the resources to be able to do that and it's very almost impossible to duplicate that at the lower levels so while it's good to emulate what's going on in the professional leagues it's not realistic to put that in place we you don't have video reviews for spotters you know at the youth level we have we have both in venue and in video so it's a very different comparison what if you don't have baselines than what you need to rely on is sort of normative data right and so you need to know what how would a typical high school student or a typical basketball player do on this test and then you lose your outliers so the people who would naturally score very low or very high so some of you normally score very high if they're concussed they may go down but still be in sort of what you consider a normal range and so you just lose your outliers when you don't have a baseline this another question from from the virtual world so probably best for you to which vestibular exercises do you prescribe right away yeah I mean I think you know discussing it with vestibular physios we try to be very simple I actually would say I don't prescribe them right away and right away meaning you know the first three to seven days and and let people do other things like aerobic exercise because sometimes they're a little bit they're a little bit too aggressive or people feel worse or feel more nauseous and I think we all have patients who went and got an assessment they say I'm worse after that but it's simple things it's it's putting sticky notes on on a wall and I tracking right to left like your smooth pursuits and then getting quicker with saccadic movements where you're going back and forth and that's what we'll do very early on where people can do it at home I personally try to stay away from any of the exercises on iPads early on just with that screen time I feel it really kind of exacerbates things Kim do you have any any thoughts on that because I know you do we have a little sheet and it has pencil push-ups on and it has some other exercises and it's like the aerobic exercise that if it's exacerbating their symptoms they should not do it they said and so both exercise and the vestibular is sort of on this exposed recover sort of method so we're gonna you know just sort of push you a little too far and then let you recover again and so we have a sheet but we use sort of the same paradigm as we do for exercise which is if it's making you worse don't do it bombs is like the let of the ACL world my one questions to the panel what's gonna be what's gonna happen in ten years you know is it gonna be functional brain is it gonna be biomarkers is an objective test for concussion you know when I was asked that question ten years ago I said we're gonna have biomarkers in ten years well we don't we don't we have found out that the biomarker question is a lot more difficult than we initially thought because it's which biomarkers at which time in recovery and what question are you trying to to answer I think that in the end it's always gonna be heavily influenced by symptoms as long as our definition of concussion is still symptoms and it really is a tautology right it's a circular argument because we're trying we're using symptoms to predict symptoms because that's what the current definition of the diagnosis is until we refine the diagnosis to be better then symptoms are gonna still hold sway and we're also it's gonna hold sway because we've we know that it's a complex injury not only because of what happens to the brain but everything that happens outside of the brain as well in terms of the psychological factors and it's hard to to say that those won't be there in ten years I would love to have a biomarker the quick you know point of care blood test it says okay you got a concussion but then the next question is okay when do you no longer have a concussion and we're not there yet yeah you know I I would say it's the same thing and maybe my analogy will be ultrasound you have people who maybe can't properly assess ligaments and they say I can see things on the ultrasound and and I mean I think it's still gonna be a clinical diagnosis but I would bet on biomarkers and as maybe to be the thing that helps us the most in ten years but I think the clinical side of things are you know we're still still people yeah Tarmish I want to get you guys take on this last year we had a performance person really push creatine monohydrate after concussion I looked at the literature and I saw conflicting results what's you guys take on it there's there's reasonable support for that and the downside is low and so there are at least a lot of power for football programs that are now supplementing with creatine fish oil and vitamin D sort of on a regular basis and we do that at our program post and pre we they do it every day I think it's four grams five grams of creatine there's no evidence so it's all theoretical right most of the nutrition nutrition research is super hard to do because there's so many conflicting things but at a sort of theoretical level there is a plausible explanation for why it may help decrease repetitive brain trauma and the downside with creating we've now had 20 years of experience with it is pretty low yeah it's interesting I think TD we got a email a week ago or from our nutritionist with about six different supplements and you know for her for post concussion and and pre concussion but you know luckily she attached all the papers and they're very limited I mean the DHEA is also another you know that's in brain armor that's also you know as part of this post concussion recovery but maybe I can pull some of those for you yeah a quick story when since we and during those is that we get in the NHL you know we get products that come to us all the time this is the new latest greatest thing right and about seven or eight years ago there was this product that was a spray you sprayed yourself in the face and you know what it made the concussion go away within ten days I'll leave it at that thanks so yeah that's a great yeah you guys that was really good

concussions

contact sports

SCAT-6

ADHD

learning disabilities

concussion prevention

exercise post-concussion

concussion subtypes

baseline testing

biomarkers

Dr. Ruben Etchemendia